On a February evening, five Delray Beach city commissioners listened intently from the dais as Florida’s Surgeon General Joseph Ladapo urged against adding fluoride to their city water. Ladapo provided data and referred to studies to convince the commissioners, warning that adding fluoride to the water reduces children’s IQ and increases the potential for attention deficit hyperactivity disorder.
“It’s like playing with fire to keep using it,” he told them.
As Ladapo road-trips across the state, he often persuades cities to stop adding fluoride to their water. On that night in Delray, though, he failed. Commissioners finished their debate with a vote to continue the city’s decades-long practice of adding fluoride to its drinking water.
Ladapo’s defeat did not deter him. The next stops on his anti-fluoridation tour included Lee and Bartow counties. In March, he may be headed to Miami-Dade for a second shot at convincing officials to end community fluoridation.
Almost all water contains some naturally occurring fluoride, but usually at levels too low to prevent cavities. For nearly 80 years, local governments have been adding fluoride to water supplies to prevent tooth decay. Recently, though, fluoridation has become a topic of debate in Florida, with dental and pediatric associations facing off against politicians and activists.
In November, Ladapo held a news conference and released guidance for government leaders to end water fluoridation because of the risk it poses. His stance mirrors that taken by President Donald Trump’s HHS pick, Robert F. Kennedy Jr., who posted on social media in November that fluoride is linked to various health problems. Since then, about a dozen Florida municipalities, including Stuart, Palm Bay and Naples, have voted to discontinue adding fluoride to their water.
Palm Beach, Broward, and Miami-Dade counties add fluoride to their county water systems. Over the last decade, all three have had comparatively low rates of emergency department visits for dental conditions. The findings reflect a statewide trend, according to a South Florida Sun Sentinel analysis of state health data.
The analysis shows that over the last decade, Florida counties in which 90% or more of their residents received fluoridated drinking water have had lower average rates of hospital ED visits for dental conditions than those that don’t add fluoride.
Counties like Putnam and Columbia, in which less than 10% of their residents received fluoridated drinking water, saw dental ER rates more than twice those of South Florida counties. While water fluoridation may not be the only factor involved, the data indicates it does play a role in dental issues.
Public health experts have emphasized that the standard amount added, 0.7 milligrams of fluoride per liter of water, is not dangerous and serves an important purpose.
“If you don’t add fluoride, you will see a definite increase in the number of cavities, especially in low-income areas where it’s more difficult to see a dentist and get fluoride treatments,” said Jeff Ottley, president of the Florida Dental Association and a family dentist in Milton.
Both sides of the debate use studies to make their arguments.
Why add fluoride?
The Florida Dental Association has strongly endorsed fluoridation, pointing to research supporting the assertion that brushing with fluoride toothpaste alone is insufficient to curb tooth decay.
“Adding optimal amounts of fluoride into our community water supplies can prevent at least 25% of tooth decay in children and adults, reducing the need for costly dental treatments,” the association said in a statement released after Ladapo held a news conference in November and called fluoridation “public health malpractice.”
Ottley says children and seniors will suffer in cities or counties that stop adding it to their water.
“As you get older and take multiple medications, they tend to cause dry mouth,” Ottley said. “Without the added fluoride in the water, there is little opportunity for fluoride to get on the surfaces that are very susceptible to cavities. Toothpaste doesn’t stick to root surfaces as well. It’s gone after you brush, whereas drinking water all day can keep a steady level of fluoride on the surface.”
With children, Ottley says, fluoride in the water helps to strengthen their developing teeth enamel, making them more resistant to cavities.
Florida pediatricians also support adding fluoride.
The Florida Chapter of the American Academy of Pediatrics believes this practice is critical to ensuring the health of children, especially those in poor communities.
“Dental caries (tooth cavity) is the most common chronic disease in childhood and disproportionally affects children of lower socioeconomic status who are less likely to have access to dental care,” the pediatric academy said in a news release.
The pediatricians say research backs up the fact that the level of fluoride in Florida’s drinking water is at the level where it doesn’t cause harm. “Over 3,000 studies from the U.S. and abroad are available addressing the safety and efficacy of fluoridating the water supply.”
Dr. Johnny Johnson, a retired Florida dentist and president of the American Fluoridation Society, said studies conducted in two locations — Juneau, Alaska, and Alberta, Canada — found that when fluoride was removed, the rates of cavities increased dramatically in children.
“Fluoride in toothpaste alone is not enough, he said. “They work together.”
The argument against fluoride
Ladapo points to research that fluoride is toxic, and he has already helped persuade at least 13 municipalities to stop fluoridating their water.
Ashley Malin, assistant professor of epidemiology at the University of Florida, has been researching the health impacts of fluoride exposure since 2013. Her most recent study examined fluoride concentration in the urine of pregnant, low-income Hispanic women in Los Angeles. Her research found that higher fluoride levels in pregnant women were linked to increased odds of their children exhibiting neurobehavioral problems such as anxiety, depression and symptoms of autism at age 3.
“Community drinking water is not the only source of fluoride exposure, but it is the main source for adults in the United States,” Malin said, adding that fluoride also is ingested through food and drinks such as black tea, canned soup and condiments and through fluoride-heavy pesticides on produce. Alongside the drinking water, fluoride accumulates until dangerous levels are present in the human body.
“What we found was that the level was 1.2 milligrams (of fluoride) per liter in the pregnant women’s urine that was associated with nearly double the odds of the children having clinically relevant neurobehavioral problems.”
Malin’s study was the first United States sample to research early-life fluoride exposure and neurobehavioral outcomes. Studies in Mexico and Canada examined neurodevelopmental outcomes in young children, including a negative effect on IQ. Those studies found that each 0.5 milligram per liter increase in fluoride was associated with about a two-and-a-half point IQ reduction.
According to Malin, the reduction in IQ points caused by fluoride could have a significant effect on a population’s intelligence over time.
The additives used for community fluoridation are byproducts of phosphate fertilizer production.
“Although fluoride does naturally occur, what we’re getting in the community drinking water is quite different than that. I would liken those additives more so to chemical mixtures that also contain fluoride,” Malin said.
Marc Edwards, professor of civil engineering at Virginia Tech, has studied fluoride in water samples throughout the United States. Edwards believes that fluoridated dental products can protect children’s teeth without the need for community fluoridation.
“Putting the fluoride in toothpaste has benefits to your teeth, but doesn’t have the same problem with ingestion, because you essentially bathe the teeth to get the benefits. You don’t swallow the toothpaste or the fluoride in the mouthwash,” Edwards said.
Edwards believes fluoridated water is an inefficient way to protect teeth.
“Dosing fluoride to drinking water is just incredibly inefficient and polluting, because we only eat or drink 1% of the water,” Edwards said. “So at a minimum, 99% of the fluoride they put in the water doesn’t provide any benefit at all because we don’t consume it, or it doesn’t contact our teeth in any way, shape, or form, yet it goes into the environment.”
According to Edwards, fluoride has a negative impact on bone density at high levels, but adds to the structural strength of teeth at lower levels.
“It’s kind of an interesting case where the dose makes the poison.”
What a Sun Sentinel analysis shows
In 2023, about 113,000 emergency department visits in Florida for patients ages 0 to 64 were due to dental conditions that were potentially avoidable, such as cavities or gingivitis.
The South Florida Sun Sentinel compiled hospital ED visits from dental conditions over a decade through 2023 and found Florida counties with the lowest rates of visits are those in which 90% or more of their residents received fluoridated water. Most counties with the highest rates of ED visits for dental conditions over the decade are those that had less than 10% of their population receiving fluoridated water.
According to the Florida Department of Health, about 70% of Floridians have fluoridated drinking water. Florida residents can learn whether their city or county adds fluoride by visiting the Florida Department of Health’s Public Water Systems Actively Fluoridating webpage.
Can Florida cities and counties afford to take a chance?
While advocates on both sides flood inboxes of city commissioners across the state with information on the issue, one fact cannot be disputed: Florida already has a poor track record for dental health.
The state ranks last in the nation for the percentage of children who have seen a dentist in the past year, according to a National Survey of Children’s Health.
In addition, about one in five children in the state are living with untreated cavities.
At least 7 million people in Florida face barriers to accessing preventive dental care, either due to a lack of dentists who accept Medicaid or because they live in areas designated as dental-care deserts.
“Florida has one of the most difficult dental access problems in the country,” said Dr. Frank Catalanotto. “Without regular dental care, a population is more susceptible to dental disease.”
Catalanotto said Floridians in municipalities that eliminate fluoride will see the effect within a few years: “We are going to have more children with cavities and probably more adults with cavities too.”
Going forward in Florida
Public health experts want to see more U.S. research on fluoride’s effect — at the levels used most commonly in public water supplies.
“There’s a lack of long-term, high-quality research,” Johnson said. “Everyone is calling for a robust study on fluoride levels naturally existing and when added at low and high levels.”
South Florida Sun Sentinel health reporter Cindy Goodman can be reached at cgoodman@sunsentinel.com.